NSAID advice for heart disease patients

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The American Heart Association recommends a stepwise approach to the pharmacological management of musculoskeletal pain (e.g., osteoarthritis, rheumatoid arthritis) in patients with or at risk of cardiovascular disease. Acetaminophen, acetylsalicylic acid (ASA), tramadol or short-term opioid analgesics should be recommended first-line. When these agents are ineffective, poorly tolerated or inappropriate, a non-COX-2-selective nonsteroidal anti-inflammatory drug (NSAID) (e.g., naproxen) should be tried. If this is unsuccessful, NSAIDs should be prescribed in order of increasing COX-2 selectivity (e.g., ibuprofen, then diclofenac), reserving the more COX-2 selective NSAIDs (e.g., celecoxib) as a last choice. Increasing degrees of COX-2 selectivity are associated with augmented cardiovascular risk, while increasing degrees of COX-1 selectivity are associated with augmented gastrointestinal risk. The full guidelines are available online here.